Hepatic surgery

The acceptability by our society of such a scheme would have to be explored. Some may mistakenly regard it as official condonation of something that should be opposed strongly, rather than as an attempt at solving a pressing problem in a realistic manner. It may be argued that this matter should be left to parents or religious bodies. Certainly, help from both those quarters would be most valuable; but they have appeared to be reluctant to tackle the job in the past, and they would be more difficult to train in delivering the tuition than educational personnel. What is the role of doctors in the control of venereal disease? Clinical management and assisting the health authority in implementing the accepted administrative measures are clearly their duty, and the few seriously involved in health education have an important part in organizing the prevention. But it must be recognized that venereal disease is a social rather than a medical problem, related to customs, mores, attitudes and ways of life; the traditional administrative and clinical approaches are still needed, but they will not solve the problem.

The acceptability by our society of such a scheme would have to be explored. Some may mistakenly regard it as official condonation of something that should be opposed strongly, rather than as an attempt at solving a pressing problem in a realistic manner. It may be argued that this matter should be left to parents or religious bodies. Certainly, help from both those quarters would be most valuable; but they have appeared to be reluctant to tackle the job in the past, and they would be more difficult to train in delivering the tuition than educational personnel.
What is the role of doctors in the control of venereal disease? Clinical management and assisting the health authority in implementing the accepted administrative measures are clearly their duty, and the few seriously involved in health education have an important part in organizing the prevention. But it must be recognized that venereal disease is a social rather than a medical problem, related to customs, mores, attitudes and ways of life; the traditional administrative and clinical approaches are still needed, but they will not solve the problem.

HEPATIC SURGERY
A RECENT PAPER by M. Balasegaram-on major hepatic resections illustrates the extent to which direct hepatic surgery has developed since the days when William Keen" of Philadelphia reported the removal of an adenoma of the bile ducts "by the Paquelin cautery and enucleation by the fingernail". As Balasegaram has ,pointed out before,' improved understanding of the anatomy of the liver and the availability of precise diagnostic techniques have done much to make effective liver surgery possible. Progress in diagnostic techniques in the last ten years or so has been spectacular. Needle biopsy of the liver, liver scanning, splenoportography and selective hepatic angiography have made preo.perative diagnosis a much less haphazard process.
Surgery carried out for benign conditions (parasitic and congenital Cysts, hamartomas, abscesses, trauma and benign tumours) generally produces acceptable results. Resection for primary and secondary malignant tumours has been much more disappointing. Although there are isolated reports of good survival after resection of "solitary" metastatic tumours,' it is far more common to find that both liver lobes are involved by the metastases, and that anatomical resection will not cope with the problem. Carcinoma of the gallbladder also continues to have an appallingly bad prognosis. Only about 3% of the patients treated surgically survive for five years." Primary liver cancers are most common in South-East Asia and Africa, and they are relatively rare elsewhere. In most parts of the world, hepatoma is most commonly seen late in the progress of cirrhosis. The generally disappointing results obtained in the treatment of hepatoma can be gauged from the paper by H. P. Curutchet and 1 Ba1asegaram, M., Aust. N.Z. J. Burg., 1972, 42: 1 (August). • Keen, W. W., Ann. Surg., 1899, 30: 267. "Balasegaram, M., Ann. roy. Coli. Surg. Engl., 1970, 47: 139. 'Waugh, J. W., and Woodrlngton, G. F., Amer. J. Surg., 1963, 105: 25. "Valttlnen, E., Ann. Chlr. Gynrec. Fenn., 1970, 59: suppl. 168. his colleagues: who reported experience with 65 patients in 1971 at the Medical College of Virginia. Sixty per cent of the carcinomas arose in cirrhotic livers. Only 33 of the 65 patients were considered candidates for exploration, and possible removal of the tumour. At explcration, only six were found to have tumours suitable for standard hepatic lobectomy. Of the six, there were only two longterm survivors. Reports from South-East Asia'" suggest that between 30% and 40% of hepatomas in that area are suitable for hepatic lobectomy. There is general agreement that the results of resection in cirrhotics are uniformly disappointing.
Direct hepatic surgery will achieve its best results in expert and experienced hands at large centres where skilled resuscitative and metabolic monitoring is possible. The impressive list of postoperative complications and metabolic derangements that may occur after hepatic resection have recently been documented by J. A. Pinkerton and his colleagues." The overall mortality amongst their 31 patients was 23%. Pneumonia and subphrenic abscess, stress ulceration of the stomach or duodenum, and coagulation disturbances were all recorded. There was some evidence that the incidence of stress ulceration may be higher when bile duct drainage is used as a routine measure after hepatic resection. Hypogly. cremia and hypoalbuminremia can both be prevented by infusions of glucose solutions and serum albumin preparations.
The technicalities of liver surgery are now reasonably well establtshed." 11 An understanding of the vascular anatomy of the liver is essential for any rational surgery.  Securing extrahepatic control of the relevant vascular structures is a prelude to resection, using the known interlobar or intersegmental ,planes. Hypothermia may provide some protection against hypoxia if the liver inflow must be occluded for any length of time." The technique of vascular isolation of the liver" is useful in difficult situations, particularly when massive trauma has involved the inferior vena cava or hepatic veins. Cryosurgery has been shown to be technically feasible in experimental animals," but has not yet established a place in clinical practice.
It seems, in fact, that hepatic surgery has been pushed about as far as it will go. Surgical inability to cope with hepatic malignancy or with the problems of cirrhosis and biliary atresia continues to stimulate efforts to achieve satisfactory liver transplantation. The technical challenges of this procedure are enormous, and transplantation so far has made but small impact on the general field of liver disease.

PREVENTIVE PSYCHIATRY
THE prevalence of mental illness and the cost of it, the misery and the complications caused in families leave no doubt that an effort should be made to minimize this enormous toll and to prevent rapid advances in the rates of certain illness. One person in ten will, at some time during his lifetime, require treatment for mental illness. One per cent of a total population suffers from schizophrenia, a disorder which is often serious and intractable, and which fills 20% of all hospital beds in most developed countries.' The sorry story of prevention of alienation in these mental hospital ,patients is told by Wing and Brown (1970) ," who showed that the chronic final stages of this disorder could be prevented, at the cost of employing more skilled and highly trained staff. Schizophrenia is essentially a disease which removes the patient-psychologically-from contact with others, and the earlier this process can be arrested, the easier it is to prevent relapse. This early referral, leading to secondary prevention through earlier recognition, is beneficial, but to enhance this possibility a higher degree of training of the medical ,profession is required. Even the primary prevention of schizophrenia may be imagined; the children of schizophrenic mothers constitute a high-risk group, and some are being closely followed from infancy.' Presumably the unhealthy modes of thought in the schizophrenic patient are a product of the interaction of a biological substrate with the patient's specific experience, and something can be done about the latter. These processes have not been sufficiently studied as yet, and more ,precise research into the genesis of this and other "functional" mental disorders may lead to precise methods for their prevention.
The notion of mental health services acting in situations of family crisis is brought forward by Caplan,' who suggests that preventive-therapeutic services might be brought into play in certain at-risk families.
In this country, mental health services will need to improve their public image before they are acceptable in families without an invitation, but this attitude may change.
Caplan's ideas are broadly similar to a series of suggestions made from World Health Organization sources," arising in a context of public health practice which may not always be welcome in the medical setting of a non-socialist economy. Buckle's recent paper in this Journal' comes from this public health background and attempts to tighten up thinking about primary prevention; if one sees the psychiatric breakdown as an end-point in a whole chain of ,psychogenesis involving person, environment, changed person, new environments, changing perception of them, and changing reactions, one can imagine an arrest at any point. This is why the delivery of medical care closer to points critical to social breakdown is needed for a total-push approach, as well as a controlled facilitation of the environments necessary for development, matters which involve vital questions as to the organization of medical care.
It may be readily understood that physical disorders producing mental illness can more easily be lllpproached through a public health model of action. Today tertiary neurosyphilis of the central nervous system is rare, but other preventible diseases-head Injuries, Korsakow's psychosis and cerebrovascular accidents-are beginning to be important in long-term hospital populations. Efforts are being made to establish registers of high-risk infants with metabolic errors," leading to their early treatment, and amniocentesis and chromatography have enabled Down's syndrome to be detected in the fretus.